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Ca Esophagus

Ca Esophagus Revision Notes

1. History of Dysphagia

  • Grade of Dysphagia: Assessment of the severity
  • Differential Diagnosis:
    • Solid dysphagia: Difficulty swallowing solids only
    • Solid with liquid dysphagia: Progression to difficulty with both solids and liquids
    • Nasal regurgitation and twang: Indicates possible neurological involvement
  • Cancer Esophagus Indicators:
    • Short history of symptoms
    • Smoking history
    • Progressive dysphagia specific to solids

2. Investigations

  • Upper GI Endoscopy and Biopsy:
    • Multiple biopsies for accurate diagnosis
    • Deep biopsy: Essential for staging
    • Ultrathin endoscope: Facilitates gentle dilatation and biopsy
    • Location Assessment: Upper, middle, or lower esophagus
    • Retroflex to check cardia growth
    • Negotiable vs. non-negotiable tumors: Determines potential for resection
    • Histology:
      • Squamous Cell Carcinoma vs. Adenocarcinoma
      • Consider NACT/NACRT based on type
  • CECT (Contrast-Enhanced CT) of Neck, Thorax, and Abdomen:
    • Metastases evaluation
    • Local resectability: Analyze angle of contact with vertebra and bronchus
    • Classify as early-stage or locally advanced
  • PET CT:
    • SUV uptake: Determines tumor metabolic activity
    • May alter management strategy
    • MUNICON trials (1 and 2): Guides response-based treatment adjustments
  • Bronchoscopy:
    • For mid-thoracic esophagus cases to assess tracheal invasion
  • Barium Swallow:
    • Alternative if endoscopy is unavailable
    • Helps in dysphagia evaluation and provides a roadmap
    • Detects Tracheoesophageal Fistula (TEF)
    • Assesses irresectability based on axis deviation

3. Management

  • Pre-treatment Considerations:
    • Nutritional status: Assess for pedal edema and ascites
    • Diet and nutrition planning
    • Smoking cessation
    • Chest physiotherapy: To enhance lung function
  • Neoadjuvant Therapy:
    • NACT/NACRT (Neoadjuvant Chemotherapy/Radiotherapy)
    • Protocols include:
      • CROSS
      • FLOT
      • MAGIC
  • Response Assessment:
    • Plan for surgery approximately 4-6 weeks post-therapy
    • Surgical approaches:
      • THE (Transhiatal Esophagectomy)
      • TTE (Transthoracic Esophagectomy)
      • VATS (Video-Assisted Thoracoscopic Surgery)
  • Potential Complications:
    • Post-surgical considerations and monitoring for complications

These structured notes focus on the essential aspects of Ca esophagus, covering history, investigations, and management, with key terms highlighted for rapid recall.

Clinical Trials in Ca Esophagus

1. MUNICON Trials (MUNICON 1 and MUNICON 2)

  • MUNICON 1:
    • Objective: Evaluate the role of FDG-PET in assessing response to neoadjuvant therapy for esophageal cancer, particularly gastroesophageal junction adenocarcinoma.
    • Method: Patients with FDG-avid tumors underwent PET scans after two weeks of neoadjuvant chemotherapy.
    • Results:
      • Metabolic Responders: Continued chemotherapy, leading to improved overall survival (OS).
      • Non-Responders: Early discontinuation of ineffective therapy, avoiding unnecessary toxicity.
    • Impact: Demonstrated that early metabolic response on PET could be a reliable predictor of pathological response, allowing for individualized therapy.
  • MUNICON 2:
    • Objective: Assess the impact of adding chemoradiotherapy after neoadjuvant chemotherapy in non-responders identified by PET in gastroesophageal junction cancer.
    • Results:
      • Non-Responders (to initial chemotherapy): No significant survival benefit was seen with the addition of chemoradiotherapy.
    • Conclusion: PET-based early response assessment can guide treatment but additional radiotherapy in non-responders did not improve outcomes significantly.

2. CROSS Trial

  • Objective: Evaluate the efficacy of neoadjuvant chemoradiotherapy (CRT) with surgery vs. surgery alone in resectable esophageal or gastroesophageal junction cancer.
  • Method: Used carboplatin and paclitaxel with concurrent radiotherapy (41.4 Gy).
  • Results:
    • Improved OS and progression-free survival (PFS) in patients who received CRT.
    • Higher pathologic complete response (pCR) rates in the CRT group.
  • Conclusion: CROSS protocol (chemoradiotherapy followed by surgery) became a standard of care for esophageal cancer due to significantly improved survival outcomes.

3. FLOT Trial

  • Objective: Determine the efficacy of FLOT (5-FU, leucovorin, oxaliplatin, and docetaxel) as perioperative chemotherapy for esophagogastric adenocarcinoma.
  • Method: Compared perioperative FLOT to traditional ECF/ECX (epirubicin, cisplatin, 5-FU/capecitabine).
  • Results:
    • Improved OS and disease-free survival (DFS) with FLOT compared to ECF/ECX.
    • Higher R0 resection rates in the FLOT group.
  • Conclusion: FLOT regimen is preferred over ECF/ECX for esophagogastric junction adenocarcinoma, showing better outcomes.

4. MAGIC Trial

  • Objective: Assessed the benefit of perioperative chemotherapy with ECF (epirubicin, cisplatin, and 5-FU) vs. surgery alone for gastric and gastroesophageal junction adenocarcinoma.
  • Results:
    • Significant improvement in OS and R0 resection rates with perioperative chemotherapy.
  • Impact: Established perioperative chemotherapy as a standard approach for esophagogastric adenocarcinoma.

5. CheckMate 577

  • Objective: Evaluate nivolumab (PD-1 inhibitor) as adjuvant therapy in resected esophageal or gastroesophageal junction cancer post-neoadjuvant chemoradiotherapy.
  • Method: Patients with residual disease after surgery were randomized to nivolumab or placebo.
  • Results:
    • Improved DFS in the nivolumab group.
  • Conclusion: Nivolumab became an option for adjuvant therapy in patients with residual disease post-neoadjuvant CRT and surgery.

6. JCOG9907 Trial

  • Objective: Compare neoadjuvant chemotherapy (cisplatin and 5-FU) with postoperative adjuvant chemotherapy in squamous cell carcinoma of the esophagus.
  • Results:
    • Improved OS in the neoadjuvant chemotherapy group.
  • Conclusion: Supported neoadjuvant chemotherapy as standard for squamous cell carcinoma of the esophagus in Japan.

Summary

  • MUNICON Trials: PET-based therapy adjustment in gastroesophageal adenocarcinoma.
  • CROSS Trial: Established CRT before surgery as standard for resectable esophageal cancer.
  • FLOT Trial: Preferred perioperative chemotherapy for gastroesophageal junction adenocarcinoma.
  • MAGIC Trial: Confirmed perioperative chemotherapy's role in esophagogastric cancer.
  • CheckMate 577: Adjuvant nivolumab improves DFS post-neoadjuvant CRT and surgery.
  • JCOG9907: Supported neoadjuvant chemotherapy in squamous cell carcinoma.

These trials have shaped the standard of care in esophageal cancer, with tailored approaches based on histology, staging, and response assessment methods.